A: Lisa Miliken: “There is a great list of suggested skilled terminology to use for different clinical scenarios on the ASHA website: http://bit.ly/1Xc5BD1
Basically, you want to show the reviewer that you are using your professional skills to teach/train the patient and the caregivers/staff, with your skills, which no one else could teach. Your skills are proven through your documentation with active skilled verbs such as: “instruct,” “analyze,” etc. Some examples listed on this site are:
– Instruct patient and caregiver in use and care of communication system.
– Develop maintenance program—to be carried out by patient and caregiver—to ensure optimal performance of trained skills and/or to generalize use of skills.
– For patients with chronic or degenerative conditions, evaluate patient’s current functional performance; provide treatment to optimize current functional ability, prevent deterioration, and/or modify maintenance program”
Learn more about this, and other related topics in the course “Audit Proof Your Skilled Therapy Documentation”.